The workers’ complaints centered on low wages and a lack of training, among other issues. In the NELP’s study, most respondents reported making between $7.25 an hour, the federal minimum wage, and $15 an hour. Four in five said they got fewer hours than they requested, too. Given those pay rates, about half of personal-care workers rely on programs like the Supplemental Nutrition Assistance Program, Medicaid, and the Temporary Assistance for Needy Families program—itself often difficult to get and penurious with benefits—to get by.

Thomas and other respondents said that personal relationships with their clients kept them on the job, despite the low wages, difficult working conditions, and fraud. “I’ve worked with a 97-year-old woman for the past two years. I try to treat her with so much tender loving care and she always reminds me of how much she loves me,” one worker said in the report. “I help to lift up her spirits. Home care is not just about going by the care plan. It doesn’t say ‘Comfort her’ or ‘Make her feel like she’s a part of society.’”

Improving training programs for personal-care workers might help both with the quality of the work and the quality of client life, the report indicated. The vast majority of workers said they wanted more training to improve their skills and better serve their clients. That might help with the country’s health-care cost crisis, as well. “Many acute, long-term illnesses can be cared for in the home. This was never really a babysitting job,” said Anastasia Christman, a senior policy analyst at NELP. “These workers see it as, and want to become, more specialized, to provide people with the best service for specific conditions and letting them remain in the home.” Connolly added: “I don’t want to over-medicalize the profession, but there are untapped opportunities there.”

Even absent that upskilling of the workforce, the report stressed the need for bolstering workplace protections, improving pay rates, boosting unionization rates, addressing labor misclassification, and putting in place more stringent rules on time off and benefits to aid all workers. And labor experts and state officials have long advocated for more oversight of firms supplying home-care workers, which are often subject to far less scrutiny than nursing homes and medical facilities. “If you train people well in the job, they’ll do well,” Thomas said. “If you pay people right, they’ll continue to work.”